Literature review
1 Nutritional status and its indicators
The concept of nutritional status has been referred to as the condition of the body with respect to each nutrient and to the entire state of the body's weight and condition (UNAP, 2011). This nutritional status equilibrium is antagonized by three processes namely, reduced intake of food; changes in utilization of food and nutrients and increase in nutritional requirements. A destabilization in this equilibrium will normally imply a loss or reduction in body tissues (Mengistu et al., 2014). Further, Smith and Haddad (2000) note that hours or days are just enough for inadequate nutrients to cause a series of changes in regard to energy and protein metabolism. All the above results into anthropometric changes that are characteristic of stark malnutrition or the loss of muscle. In light of this brief background, it is already clear that nutritional status is a very important and good indicator of whether one is intaking the right quantity and type of nutrients. In simple words, nutritional status can also be referred as the condition of the human body in regard to the consumption and subsequent utilization of nutrients (UNAP, 2011). A total of three famous indicators are commonly used to categorize people nutritionally and this is done with comparison to the World Health Organization International Growth Reference. These three as stated by Okoroigwe et. (2009) include height for age, weight for height and weight for age.
2 Classification of malnutrition
Mahgoub et al. (2006) explain that in infants, malnutrition may present as wasting stunting and or being underweight. Relatedly, the WHO also explains that children possessing weight-for-age indicators that are more than two or three standard deviations below the median for the international reference population (ages 0-59 months) are considered moderately or severely underweight (WHO 2011). Further, those whose height length-for-age indicator is more than two or three standard deviations below the median for the international reference population (ages 0-59 months) are considered moderately or severely stunted and those whose weight-for-height length indicator is more than two or three standard deviations below the median for the international reference population (ages 0- 59 months) are considered moderately or severely wasted. (UNICEF, 2015; World Bank, 2011; WHO, 2011)
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3 Magnitude of the problem
Malnutrition remains one of the most common causes f morbidity and mortality among children under five children throughout the World (UNAP, 2011). Globally, nearly 10 million children under the age of 5 years pass on yearly from preventable and treatable illnesses malnutrition being one of them despite effective health interventions (Mengistu et al., 2014). Malnourished children have lowered resistance to infection; therefore, they are more likely to die from common childhood ailments such as diarrheal diseases and respiratory infections. Additionally, children that are able to survive this condition still battle recurring series of diseases, are faced with lower cognitive ability and experience very low learning ability. Globally, 23.8% of children below 5 years old are stunted, 7.5% are wasted and 6.1% weigh more than they should for their age (UNICEF, 2015). In Africa, 38.6% of children under five are stunted, 28.4% are underweight and 7.2% are wasted. (Orach et al., 2008). In sub-Saharan Africa, 42.7% are stunted, 9.2% are wasted and 35.8% are underweight (UNICEF 2015). The Uganda Demographic and Health Report indicate that nearly 38% of Ugandan preschool children are stunted, 6% are wasted and 16% are underweight (UDHS, 2006). Caulfield et al. (2004) have documented malnutrition as a serious problem mostly in the developing global south countries of Asia and Africa respectively. The prevalence of underweight and stunting in South Asia has been recorded as 46 and 44 percent, respectively (De Onis et al., 2000). Chronic malnutrition has been a persistent problem for young children in Sub-Saharan Africa (Mengistu et al., 2014). Whilst Asia remains more critically affected, its malnutrition cases are steadily reducing compared to those of Sub-Saharan Africa. For instance, a study report by Sebanjo et al. (2009) indicated that undernourished people in sub? Saharan Africa increased from nearly 90 million in 1970 to 225 million in 2008 whilst it had been predicted to add another 100 million by 2015. Therefore, child malnutrition is the most lethal form of malnutrition and it thus calls for immediate intervention strategies.
2.4 The pathophysiology of malnutrition and its causes
Porter and Kaplan (2011) have explained the initial metabolic response of malnutrition being reduced metabolic rate. They further argue that the body first breaks down adipose tissue in order to supply energy and that later it may utilize protein energy when the body tissues are depleted. Additionally, visceral organs and muscles are broken down and severe weight loss occurs. (Porter, 2011). There is loss of organ weight that occurs, and this is greatest in the liver and intestines, intermediate in the heart and kidneys, and least in the nervous system. UNICEF implies through its famous UNICEF conceptual framework on malnutrition that malnourished children are at great risk of pneumonia, measles, diarrhea, and malaria. They are moreover also at a greater risk of dying from the same (UNICEF, 2015). This study uses the conceptual framework to explain factors related to malnutrition in children and its pathophysiology.
Figure 1: Shows the UNICEF conceptual framework of malnutrition
- Source: UNICEF, Strategy for Improved Nutrition of Children and Women in Developing countries, UNICEF, New York, 1990.
The conceptual framework of child malnutrition developed by UNICEF, shown in Figure 1, projects a generalized conception of how malnutrition is the outcome of particular development issues directly associated directly with the status of dietary intake and the health level of the individual (UNICEF, 1990). The level of dietary intake which is determined by the four dimensions of food security and health are the immediate determinant of a child’s nutritional status. The World Health Organization further explains that the quality of the two factors deemed as immediate determinants in influenced by the food security of the status of the household to which the child belongs to, the health of the environment in which the child survives, and the quality of the health amenities available as well care given to the child (WHO, 2010). The extent to which the above determinants are influenced in either a positive or negative manner is only incumbent on the available resources which include food availability, food accessibility, and whether the caregiver of the child is able to access these resources or not (UNICEF,2015). Unless these underlying determinants are adequately available a child cannot live an active and healthy life (WHO, 2010). A study by Kikafunda et al. (2006) further asserts that the extent to which available resources are distributed in society will heavily influence the quality of the underlying nutritional status of a child in a certain household.
A combination of basic determinants which are themselves a function of how society is organized pertaining to the structure of politics, economic structure, the institutions that regulate activities within society, social norms, social values, and political and ideological orientation among other societal factors are all linked to the availability of nutrition resources at the household level. UNICEF,1990). We then see the framework moving from factors to do with individual and household aspects to the community, regional and state aspects because indeed the state of the economy and this broad level determines a lot of factors which in turn influence the nutritional status of an individual (UNAP, 2011: UNICEF, 1990)
6 A review of similar studies
In their study, in which they investigated the influence of socioeconomic factors on the nutritional status of children in the rural community of Osun in Nigeria, Sebanjo et al. (2015) found high rates of malnutrition among children, in the region. Their results indicate that up to 23.1%, 9% and 26.7% of the children interviewed were underweight, wasted, and stunted respectively (Sebanjo et al.,2015). In a related study that also determined the prevalence and determinants of malnutrition among Under-five Children of Farming Households in Nigeria’s Kwara state, Babatunde et al. (2011) found high levels of malnutrition with their results indicated that 23.6%, 22.0% and 14.2% of the sample children were stunted, underweight and wasted, respectively. Additionally, another study done by Siddiqi et al. (2011) on malnutrition among under-five children in Bangladesh revealed a high prevalence of stunting and underweight with 42% and 40% of under-five children being stunted and underweight, respectively (Siddiqi et al.,2011).
Otgonjargal et al. (2012) also studied the nutritional status of under-five children in Mongolia and their results indicated that the prevalence of stunting, wasting and underweight were 15.6%, 1.7% and 4.7%, respectively. These results point out the high rates of malnutrition in many societies and usually prevalent among children under the age of five. In another study, Sapkota et al. (2009) also found a high prevalence of malnutrition rates in under five children in Belahara VDC of Dhankuta district in Nepal located in South Asia. The results of Sapkota et al. (2009) indicated that up to 27%, 37%, and 11% were underweight, stunted and wasted respectively.
A report from the United States Agency for International Development has documented South Sudan as the country with one of the highest rates of malnutrition in Africa with close to 22% of all children in the country battling moderate to severe acute malnutrition (USAID, 2007). This rate is even worse in the Southern parts of the country with the prevalence being twice as high as it is in other parts for the country (Ola et al., 2011).
A study conducted by Kwena et al. (2003) to assess the nutritional status of preschool children in a rural area of western Kenya revealed that, the prevalence of stunting, underweight and wasting were 30%, 20%, and 4%, respectively (Kwena et al.,2003). Relatedly, another cross-sectional survey conducted in a rural locality of Gumbrit of the same country found the overall prevalence of malnutrition in the community was high with 28.5% of the children being underweight, 24% stunted and 17.7% wasted (Edris,2006).
Other studies that assessed the same aspect included Asres et al. (2011) which found that the prevalence of stunting, underweight and wasting were 37.2%, 14.6%, and 4.5%, respectively. Additionally, the same study found that severe stunting, severe underweight and severe wasting were seen in 14.8%, 2.9%, and 0.5% of the children respectively (Acres et al., 2011); Mulugeta et al. (2005) also assessed the nutritional status among rural areas of Ethiopia’s Tigray region and found the levels of stunting, underweight and wasting to be 42.7%, 38.3% and 13.4%, respectively (Mulugeta et al.,2005). Relatedly, a cross-sectional study conducted by Taffesse (1997) had earlier highlighted this situation. Taffesse’s study in Aynalem village, Tigray region found that the overall prevalence of stunting, underweight and wasting were 45.7%,43.1%, and 7.1%, respectively (Taffesse,1997). Additionally, a study conducted by Kebede (2007) in the Gimbi district Oromia region also found that 32.4 %,23.5 %, and 15.9% of the children were stunted, underweight and wasted respectively. Further, a cross-sectional study conducted in rural kebeles of Haramaya district also revealed that the prevalence of stunting, underweight, and wasting were 42.2%, 36.6%, and 14.1%, respectively. In addition, the proportion of the prevalence of malnutrition by its level of severity indicated that 19.9% were severely stunted, 16.6% were severely underweight and 3.9% were severely wasted (Zewdu, 2012)
7 Associated factors
The causes of malnutrition are numerous and multifaceted. There seems to exist a complicated inseparable relationship that exists in a hierarchical manner among them. While recurrent disease and very poor diets are themselves caused by other numerous underlying factors, they are considered to be the immediate determinants. These two factors relate to the four dimensions of food security at the household level, the health of the environment and the availability as well as the access of health services to both babies and mothers. The underlying factors that are explained above are moreover influenced by socioeconomic and political conditions as evidenced from the UNICEF conceptual framework on malnutrition (Muller, 2005). A study conducted on malnutrition among under-five children in Bangladesh revealed that household economic status, mother’s education, father’s education, mother’s antenatal visit (s), mother’s age at birth and Mother’s BMI are the most significant factor determinants of child’s malnutrition (Siddiqi et al., 2011). Relatedly, Sapkota et al. (2019) conducted a study in the rural communities of Nigeria’s Osun state in which they found education level as a very important factor in malnutrition studies. The study results revealed that mothers who were not educated past the level of secondary school had babies that were almost two times more likely to be stunted that their counterparts who had gone past this level. Sapkota et al. (2019) also found that home overcrowding and very low incomes were associated with malnutrition particularly wasting. This is children fed on an inadequate diet stemming from competition among household members and a very small resource envelope. While investigations in regard to social class did not yield consistent results, this might be due to shifts in what the researcher termed as social class. These days social class is more of having a certain amount of income as opposed to the right of belonging to a certain group of people (Sapkota et al., 2009). In a study conducted on the prevalence and determinants of malnutrition among Under-five Children of Farming Households in Kwara State, Nigeria, malnutrition was significant associated gender and age of the child, education and body mass index of the mother, the calorie intake of the households, access to clean water and presence of a toilet in the households (USAID, 2007).
Acres et al. (2011) investigated the factors affecting nutritional status at Beta-Israel also and revealed that the main contributing factors for under-five malnutrition were sex of the child, child’s age, diarrhea episode, deprivation of colostrums, duration of breastfeeding, type of food, method of feeding, and age at which complementary feeding was introduced (Acres et al.,2011). Factors linked to the economy, social and environmental factors among others make malnutrition levels to vary among and within countries and regions. The effect of income is measured by expenditure on food which reflects a household’s income and resources (Zewdu, 2012)
Tesfaye (2009) used a Bayesian Approach to investigate predictors of nutritional status in Ethiopia. In his results, he finds that the main predictors of children's nutritional status were a place of residence, maternal education, occupation of mother, Preceding birth interval, source of water drinking, age of the child, sex of the child, Mother’s BMI and age of mothers (Tesfaye,2009) A study conducted in rural Tigray region revealed that, a very high proportion of the mothers (80%) initiated feeding of newborns with pre-lacteal feeds primarily butter or water. Factors like the age of the child, maternal nutritional status, quality and quantity of complementary foods, and area of residence were the major predictive factors to child malnutrition (Mulugeta et al., 2007). Children’s age groups were an important and significant factor in regard to the severity of underweight and stunting in Aynalem village in the Tigray region. The age group f 12 months to 24 months manifested a high incidence of both stunting and underweight whilst the 0 months to 6 months group presented with lower levels of stunting, underweight, and wasting (Taffesse et al., 1997). Income levels, education, sex and age of the child, access to healthcare, nutritional status of the respondents’ parents, access to social amenities like clean water and sanitation, and adequate primary health care were the most significant factors associated with malnutrition. As already hinted, predisposing factors that are contributing are bound to vary among and within regions as well as over time different time periods. Therefore, assessing contributing factors linked to a certain locality and region is important for contextualization and designing intervention strategies. A Survey of available literature indicates that factors like knowledge of health practices and caring level, educational level of parents, and access to or interactions of the age of the child have a strong effect on household and community variables in which the child grows up (Meril, 1984). The key factors that significantly influenced stunting included the birth size or weight of the child, education level on the paternal side and maternal decision-making power.
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